Respiratory Pharmacy & the Ward
Pharmacist experience
by
Abdol Malek bin Abd Aziz, MSc
Respiratory pharmacy
• Emphasis on pharmaceutical care of respiratory patients
plus
• Other conditions that the patient is concurrently suffering
Respiratory Pharmacy
NHMS 1996 - Findings
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High percentage (62.4%) not on inhalers
Mild asthmatics: 65.3%
Moderate : 52.1%
Severe : 23.7%
Compliance / adherence
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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)
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Aziz AMA, Ibrahim MIM. Med J Malaysia 1999.
** Aziz AMA, Senthil N, Jenny W. J Pharm Sci. 2003 (in press)
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
Inhaler technique
• “good” rating ranged from 5-86% using MDIs
• Technique improved after proper training*
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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 R&D Farmasi, Kota Bharu 2002.
* Cochrane MG, Bala MV, Downs KE et al. Inhaled corticosteroids for asthma therapy: patient compliance, devices ,
and inhalation technique. Chest 2000;117(2):542-550
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 1996;153:1636-1640.
#
Newman SP, Millar AB, Lennard-Jones TR et al. improvement of pressurised aerosol deposition with Nebuhaler
spacer device. Thorax 1984;39:936-941.
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
Asthma in children
Children:
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Dry powder inhalers has greater systemic effects than MDIs§
• Pharmacists: recommend MDI with spacer device for children.
§ Kereem
E . Ann Allergy Asthma International 2002;89.
Pharmacist’s roles
• As educator and support person
• Counsel on role of each medication
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Difference between preventer – reliever
Emphasise safety of inhaled c’steroids
Discuss adverse effects – ways to minimise
Check and correct proper use of inhalers
Encourage use of spacers and peak fl. meters
Pharmacist’s roles
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Check compliance – 56% noncompliance rate1
• Check usage of medications for other illnesses, OTC products,
GP’s drugs, etc
• Dispels myths about asthma and inhaler use
• Encourage asthma action plan
Objective
• To have an influence on prescribing and related
clinical practice
How to start?
• Ward pharmacy
• then
• Respiratory pharmacy
Ward pharmacy
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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
At the ward…
• Familiarise with the ward- acquaint with ward staff ie. sister &
nurses
• Ward procedures
• Own reading on common drugs used
• develop confidence
Ward rounds
• Consultant’s rounds: already have a high level
of interest in optimising drug therapy
• Vigilant on ADR and side effects
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
• Becoming prepared
provides…
Confidence
Clerking
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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
Things to do…
• Estimate creatinine clearance ClCr if the serum creatinine is
>150µmol/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
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
Attending ward rounds
• Be PUNCTUAL
• Degree of involvement and pharmacist’s role depend on the
leading physician
• Doctors may undertake management or teaching role or both
• They may not ask for pharmacist’s comments
A successful attendance in ward rounds
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Adequate preparation
Being tactful, yet assertive
prioritise
Regular attendance
Present info on a problem concisely
Provide adequate follow up
Pharmacist’s 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
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
Nursing profession development
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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.
Specialisation
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Extra qualifications preferable
Sometimes not necessary
MSc, MPharm
PhD
• Experience, confidence, way of thinking, networking,
research-oriented, etc
Specific situations
• Asthma
• Counselling
• Pharmacoherapy issues ie. Drug of choice: â-2 agonists
(short-acting, long-acting, corticosteroids (inhaled , oral),
• Drug forms: inhalers, oral tablets, nebs
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
What others have achieved…
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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 2002;59. p. 1829.
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.
COPD
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
C….confirm...
• Exclude asthma, cardiac disease etc
• Assess severity
• Assess reversible components
• Identify complications and co-existing conditions
– history, examination, spirometry, xray chest, FBE
O….optimise….
– Smoking cessation
– Optimise drugs
• safe and effective - don’t over-prescribe
– Treat complications
– Optimise psychosocial issues
– Optimise nutrition (consider dietician)
– Encourage exercise (consider physio gym)
– Pulmonary rehabilitation
– Lung reduction surgery or transplantation
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
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
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)
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
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
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 > 300ml/min adults)
• Measures early deterioration before pt. feels the change in his disease
{diabetics monitor blood sugar, asthmatics measure lung
function…}
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 ) @1.30pm
• Coordinated by the Resp. Rehab. Clinic
• Pharmacist
• Talked about “Medications and Airways Disease”
PRP team
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Respiratory physician (Chairman),
Technical officer, Respiratory Function Unit
Clinical Nurse Consultant, Respiratory Rehab Clinic
Clinical Pharmacist
Physiotherapist
Rehabilitation Counsellor
Dietician
Occupational therapist